Method for Detecting and Preventing Fraudulent Healthcare Claims

ABSTRACT

A computer implement method that assist healthcare payers in identifying potentially fraudulent claims and which requests confirmation preferably from a healthcare provider or patient of services rendered by the healthcare provider or products received by the patient. Confirmation of equipment and services can occur at different times in the settlement process including, but not limited to, prior to payments being made to health care providers.

This application is a continuation of U.S. application Ser. No.13/270,255, filed Oct. 11, 2011, which application claims the benefit ofand priority to U.S. Provisional Patent Application Ser. No. 61/391,953,filed Oct. 11, 2010. All of the above-identified applications areincorporated by reference in their entireties for all purposes.

1. FIELD OF THE INVENTION

The present invention relates generally to healthcare claims and moreparticularly to a method for helping to detect and reduce fraudulenthealthcare claims.

2. BACKGROUND OF THE INVENTION

In the current environment, healthcare spending accounts for over 15% ofthe GDP according to a 2004 General Accounting Office report toCongress. Of the funds expended for health care each year, the NationalHealth Care Anti-fraud Association (NHCAA) estimated that at least 3%was lost to fraud. This amounts to in excess of $60 Billion lost tofraud each year.

Health Care fraud can manifest itself in a variety of ways. Providerscan bill for services or equipment not provided, administering teststhat are not medically necessary, administering more expensive tests andequipment (up-coding), multiple billing for services or unbundling oflab tests performed together among others. There are even instances ofpolicy holders letting others use their health care cards to receiveimproper benefits as well as instances of medical identity theft thatcontribute to the ongoing health care fraud problem.

The present invention is directed to a novel method for helping todetect and reduce fraudulent healthcare claims.

SUMMARY OF THE INVENTION

The present invention generally describes a novel method that assisthealthcare payers in identifying potentially fraudulent claims and inconfirming receipt of equipment and services at different times in thesettlement process including, but not limited to, prior to paymentsbeing made to health care providers. In connection with the descriptionof the present the following definitions will be used:

Definitions

Health Care A method, process and/or system to analyze health careclaims and/or Claim remittance data for the purposes of helping in thedetection of Integrity potential fraud and abuse. It additionally caninclude a process to System verify services and supplies provided withor by the healthcare provider and/or patient. 835 A HIPAA compliantelectronic data format utilized for the purposes of remitting paymentsto healthcare providers for services rendered. However, this format isnot considered limiting and other HIPAA or non-HIPAA compliantelectronic data formats can be used and are considered within the scopeof the invention. 837 A HIPAA compliant electronic data format utilizedfor the purposes of billing payers for healthcare services rendered toits members. However, this format is not considered limiting and otherHIPAA or non-HIPAA compliant electronic data formats can be used and areconsidered within the scope of the invention. Analytics A proprietarysystem designed to process 835 and/or 837 files or other Engine fileformats and determine the likelihood of potential fraud and abuse basedon analytical data and rules including self “learning” algorithms. Thisrules engine is preferably where the determination of a likelihood of afraudulent claim and/or abusive claim is made. Preferably, a base set ofrules are provided with the system dynamically creating new rules asmore data is introduced into the system. The engine can also take intoaccount new claims information for statistical analysis, responsesreceived from patients/providers to claim inquiries, and other dataobtained through the system over time. 1010 Data A proprietaryelectronic database system utilized by the Health Care Warehouse ClaimIntegrity System to store and process health care claim data andconfirmation records. Though not limiting, it is preferred that thedatabase system be relatively large and permit the use of extremelylarge data sets and also that it can perform queries across theseextremely large data sets almost instantly. Detection A set of rulesdetermined through analytical analysis of data that is Criteria utilizedto determine if a claim for health care service is potentiallyfraudulent. Criteria includes but is not limited to excessive billingamounts, higher costs per patient, excessive patients per physician,increased number of tests per patient, abnormal distance betweentreatment location and patient's residence and a higher rate ofprescription for certain drugs. Detection Criteria also includes thecreation of rules as a result of self “learned” algorithms.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 is a flow diagram of the health care claim integrity systemdetection process in accordance with the present invention; and

FIG. 2 is a flow diagram of the health care claim confirmation processin accordance with the present invention.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 shows a preferred workflow for importation, analysis,confirmation and intercept of potentially fraudulent health care claimsin accordance with the present invention. At step F1 a healthcare claimdata from an 835 Remittance Advice, 837 Claim File or other HIPAA ornon-HIPAA compliant electronic data format can be imported into theanalytics engine. At step F1 b, utilizing proprietary rules andtechnology, the analytics engine makes a determination as to whether aclaim is suspected of potential fraud and/or abuse and to divert suspectclaims identified by the analytics engine for confirmation.

At step F1 c for claims meeting the criteria and requiring confirmationof services provided and/or products received, the health care providerand/or the patient is contacted preferably, though not limiting, throughan automated system via phone, email and/or SMS messaging to confirmthat services or products were provided or received. Other messagingsystems can also be used, such as, but not limited to, instantmessaging, Facebook messaging, etc. and all are considered within thescope of the invention. Depending on the specific circumstances,confirmation may be required by the health care provider only, by thepatient only, or by both the health care provider and patient.

As seen in step F1 d for claims not meeting the criteria and thus notrequiring confirmation of services provided and/or products received,the claim record is updated in the electronic data warehouse to reflectsuch and that the claim was reviewed. As seen in step F1 e for claimsidentified in F1 b (meeting the criteria as potentially suspect orfraudulent and needing further review) where the patient or provider didnot acknowledge the patient's receipt of services and/or products, theclaims intercept process is initiated which could either prevent theclaim from being paid to the provider without further review and/orserve as an additional data point along with other factors to identifysuspect claims, providers, physicians and/or patients involved inschemes involving collusion among them.

As seen in step F1 f for claims identified in F1 b where the patient orprovider provided a positive acknowledgement for the patient's receiptof services and/or products, the claim record is updated in theelectronic data warehouse to reflect such and that claim has beenreviewed. This data point is then considered by the analytics engine forfuture claims processed by it. The invention can specifically include,but is not limited to, “seeding” confirmation messages sent to differentparties involved in the transaction. Seeding in this context meansintentionally introducing requests for confirmation of services orproducts that were not in fact received from or provided by theprovider. Responses to these “seeded” requests for confirmation are usedby the analytics engine to determine if collusion is involved.

FIG. 2 shows the workflow for confirming the patient's receipt ofservices and/or products with the confirmation coming from a patientand/or physician and also illustrates where this workflow is performedin relationship to the various steps shown in FIG. 1 (which is alsoreproduced in smaller size in FIG. 2). In step F1 a of FIG. 2 for claimsmeeting criteria and requiring confirmation of services and/or products,the health care claim integrity system contacts the provider and/or thepatient preferably, though not limiting, through an automated system viaphone (i.e. any type of phone—cellular phone, landline, satellite phone,etc.), email and/or SMS messaging to confirm that services and/orproducts were provided or received. Non-limiting examples of the type ofmessage that can be sent to the provider and/or patient are illustrated.Other messages can also be sent and are considered within the scope ofthe invention.

At step F1 b of FIG. 2 the patients and/or providers must either enter aspecific character or click on the appropriate hyperlink to indicatetheir response. For a non-limiting example, the patient or provider maypress the “1” button on his or her phone for a “yes” response or pressthe “2” button for a “no” response. Other configurations, messages,phrases and numbers can be used and all are considered within the scopeof the invention. Responses are received by the health care claimintegrity system and utilized to update claim records.

The health care claim integrity system and method described above canprovide administrative, clinical and/or financial benefits to healthcarepayers, providers and patients alike, including, but not limited to, thefollowing public benefits:

-   1. Reduce the incident of health care fraud and abuse, resulting in    significant cost savings to the payer, provider and patient.-   2. Reduce manual effort involved in identification of potentially    fraudulent and abusive charges-   3. Reduce manual effort involved in the confirmation of receipt of    medical services and supplies.-   4. Lower administrative costs due to false claims-   5. Minimize false medical data reported on a patient's health care    record

Any computer/server/electronic database system (collectively “ComputerSystem”) capable of being programmed with the specific steps of thepresent invention can be used and is considered within the scope of theinvention. Once programmed such Computer System can preferably beconsidered a special purpose computer limited to the use of two or moreof the above particularly described combination of steps (programmedinstructions) performing two or more of the above particularly describedcombination of functions

All amounts, component or part locations, configurations, values,percentages, materials, orientations, etc. discussed above or shown inthe drawings, if any, are merely by way of example and are notconsidered limiting and other amounts, component or part locations,configurations, values, percentages, materials, orientations etc. can bechosen and used and all are considered within the scope of theinvention.

Unless feature(s), part(s), component(s), characteristic(s) orfunction(s) described in the specification or shown in the drawings fora claim element, claim step or claim term specifically appear in theclaim with the claim element, claim step or claim term, then theinventor does not consider such feature(s), part(s), component(s),characteristic(s) or function(s) to be included for the claim element,claim step or claim term in the claim when and if the claim element,claim step or claim term is interpreted or construed. Similarly, withrespect to any “means for” elements in the claims, the inventorconsiders such language to require only the minimal amount of features,components, steps, or parts from the specification to achieve thefunction of the “means for” language and not all of the features,components, steps or parts describe in the specification that arerelated to the function of the “means for” language.

While the invention has been described and disclosed in certain termsand has disclosed certain embodiments or modifications, persons skilledin the art who have acquainted themselves with the invention, willappreciate that it is not necessarily limited by such terms, nor to thespecific embodiments and modification disclosed herein. Thus, a widevariety of alternatives, suggested by the teachings herein, can bepracticed without departing from the spirit of the invention, and rightsto such alternatives are particularly reserved and considered within thescope of the invention.

What is claimed is:
 1. A computer implemented method for automaticallyidentifying potential collusion with respect to a healthcare claim afterthe healthcare claim has been electronically submitted for payment, saidmethod comprising the steps of: (a) receiving healthcare claim data byan analytics engine of a computer; (b) determining by the analyticsengine based on programmed rules whether or not a healthcare claim basedon the received healthcare claim data is potentially suspect orfraudulent; (c) diverting for confirmation any healthcare claimdetermined to be potentially suspect or fraudulent by the analyticsengine based on programmed rules; and (d) contacting a healthcareprovider or patient associated with the healthcare claim regardingwhether one or more services listed in the healthcare claim wererendered by the healthcare provider or whether the patient received oneor more products listed in the healthcare claim where the healthcareclaim is diverted in step (c) or updating an electronic data warehousethat the healthcare claim was reviewed and does not require confirmationwhere the analytics engine determines in step (b) that the healthcareclaim is not potentially suspect or fraudulent; and (e) if thehealthcare claim is diverted in step (c) requesting confirmation of oneor more services being rendered or one or more products being receivedthat are known by said analytical engine to not to have been provided orreceived.
 2. The computer implemented method of claim 1 wherein saidstep (d) comprises automatically contacting the healthcare provider orpatient through phone, email, SMS or instant messaging.
 3. The computerimplemented method of claim 1 further comprising the steps: (f)receiving confirmation from the healthcare provider or patient that theone or more services were rendered or that the one or more products werereceived; and (g) updating an electronic data warehouse that thehealthcare claim was reviewed and that confirmation was received fromthe healthcare provider or patient.
 4. The computer implemented methodof claim 1 further comprising the steps of: (f) initiating a claimintercept process where no confirmation is received from the healthcareprovider or patient that one or more services were rendered or that oneor more products were received; and (g) updating an electronic datawarehouse that the healthcare claim was reviewed, that no confirmationwas received from the healthcare provider or patient and that a claimintercept was initiated.
 5. A computer implemented method forautomatically identifying potential collusion with respect to ahealthcare claim after the healthcare claim has been electronicallysubmitted for payment, said method comprising the steps of: (a)electronically receiving a healthcare claim for payment from ahealthcare provider by a healthcare claim integrity computer system of ahealthcare payer where the healthcare claim identifies one or moreservices or one or more products provided to a patient by the healthcareprovider, the healthcare claim integrity computer system including ananalytics engine in electronic communication with an electronic datawarehouse, the analytics engine programmed to determine the likelihoodof potential fraud and abuse for a submitted healthcare claim and isprogrammed to consider data points from the submitted healthcare claimin future potential fraud and abuse determinations by the analyticsengine; (b) automatically creating an electronic “seeded” request by theanalytics engine listing one or more services or products in the requestthat are not listed in the received submitted healthcare claim; (c)electronically forwarding the “seeded” request by the healthcare claimintegrity computer system to the healthcare provider or patient askingthe healthcare provider or patient to confirm whether or not the one ormore services or products in the request were provided to the patient bythe healthcare provider; and (d) electronically and automaticallyidentifying, by the healthcare claim integrity computer system,potential collusion when an indication is received by the healthcareclaim integrity system from the healthcare provider or patient statingor representing that the one or more services or products in the“seeded” request were provided to the patient by the healthcareprovider.
 6. The computer implemented method of claim 5 furthercomprising the step of automatically updating the programmed detectioncriteria used by the analytics engine for future healthcare claims bythe healthcare claim integrity computer system based on data points fromthe submitted healthcare claim and data saved concerning confirmation ofthe submitted healthcare claim or an intercept of the submittedhealthcare claim.
 7. A computer implemented method for automaticallydetecting whether a healthcare claim is fraudulent after the healthcareclaim has been electronically submitted for payment, said methodcomprising: (a) receiving an electronic healthcare claim for paymentfrom a healthcare provider by a healthcare claim integrity computersystem of a healthcare payer, the healthcare claim integrity computersystem including an analytics engine in electronic communication with anelectronic data warehouse, the analytics engine programmed to determinethe likelihood of potential fraud and abuse for a submitted healthcareclaim and is programmed to consider data points from the submittedhealthcare claim in future potential fraud and abuse determinations bythe analytics engine; (b) importing electronic healthcare claim datafrom the received electronic healthcare claim into the analytics engine,said healthcare claim data identifying one or more services provided toa patient or one or more products received by a patient from thehealthcare provider; (c) electronically determining by the analyticsengine based on programmed detection criteria and the importedelectronic healthcare claim data whether or not the received healthcareclaim is suspect or fraudulent; (d) automatically diverting forconfirmation by the healthcare claim integrity computer system anyreceived healthcare claim determined to be suspect or fraudulent by theanalytics engine in step (c); (e) for healthcare claims diverted in step(d) electronically contacting the healthcare provider or the patient whoreceived the one or more services or products through an automatedsystem of the healthcare claim integrity computer system; (f)electronically determining by the healthcare claim integrity computersystem whether one or more services or products listed in the healthcareclaim were actually provided by the healthcare provider; (g) requesting,by the healthcare claim integrity computer system, electronicconfirmation from the healthcare provider or patient contacted in step(e) as to whether the one or more services or products listed in thehealthcare claim were received; and (h) (i) automatically initiating anelectronic intercept of the healthcare claim by the analytics engine forfurther investigation of the healthcare claim where the healthcareprovider or patient fails to confirm that one or more services orproducts were received after a certain period of time; or (ii)electronically receiving, by the healthcare claim integrity computersystem, a positive electronic acknowledgment from the healthcareprovider or patient confirming that the one or more services or productswere received and updating an electronic data warehouse that thehealthcare claim was reviewed; and (i) updating an electronic datawarehouse by the healthcare claim integrity system indicating that thehealthcare claim is not suspect or fraudulent for a healthcare claimreceiving a positive acknowledgment in step (h)(ii) or that a claimintercept was initiated in step (h)(i).
 8. The computer implementedmethod of claim 7 wherein said step of contacting a healthcare provideror patient comprises automatically contacting the healthcare provider orpatient through phone, email, SMS or instant messaging.